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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800147
Report Date: 05/03/2021
Date Signed: 05/03/2021 04:11:56 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/26/2021 and conducted by Evaluator Tricia Danielson
COMPLAINT CONTROL NUMBER: 18-AS-20210426154928
FACILITY NAME:MONTCLAIR ROYALE SENIOR LIVINGFACILITY NUMBER:
361800147
ADMINISTRATOR:SANTOS, ANNAMARIEFACILITY TYPE:
740
ADDRESS:9685 MONTE VISTA AVETELEPHONE:
(909) 621-3545
CITY:MONTCLAIRSTATE: CAZIP CODE:
91763
CAPACITY:236CENSUS: 106DATE:
05/03/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Araceli Soto, Care CoordinatorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility refused to readmit resident back after hospital stay.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tricia Danielson contacted the facility to initiate a complaint investigation. LPA identified herself and discussed the purpose of the call with Care Coordinator (CC) Araceli Soto.
During today's visit, LPA interviewed CC Soto regarding Resident #1 (R1) and the details pertaining to R1's recent hospitalization and discharge from the hospital. Regarding the allegation "facility refused to readmit resident back after hospital stay": It was alleged that the facility refused to readmit R1 following their hospital stay for exhibiting dangerous behaviors to others. On 4/18/21, the hospital contacted the facility to arrange R1's discharge after being found to no longer be a danger to others. Upon making contact with the facility, the hospital was told the facility refused to readmit R1. Today's interview with CC Soto revealed the facility did refuse to readmit R1 based on their behavior prior to their hospitalization. CC Soto stated no eviction notice was served to R1 based on the facility's belief that due to R1's short residency at the facility, an eviction notice was not required. Based on LPA's interview which was conducted, the preponderance of evidence
(CONTINUED ON LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 18-AS-20210426154928
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MONTCLAIR ROYALE SENIOR LIVING
FACILITY NUMBER: 361800147
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2021
Section Cited
HSC
1569.269(a)(22)
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Enumerated rights- (a) Residents of resid- ential care facilities for the elderly shall have all of the following rights: (22)be pr- otected from involuntary...evictions in vio- lation of state laws and regulations..."inv- oluntary” means an...eviction that is initia- ted by the licensee, not by the resident. This requirement was not met as evidenc- ed by:
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The facility stated they will submit a statement of understanding of the regulation cited and contact the hospital to arrange for R1's return to the facility with the appropriate care until they have moved from the facility. POC will be submitted by 5/17/21.
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The Licensee did not ensure R1 was provided a 30 day eviction notice as required by law. Based on interviews which were conducted, the facility refused to readmit R1 following thier hospitalization. This poses a potential health, safety and personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20210426154928
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MONTCLAIR ROYALE SENIOR LIVING
FACILITY NUMBER: 361800147
VISIT DATE: 05/03/2021
NARRATIVE
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(CONTINUED FROM LIC 9099)
standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code Of Regulations, Title 22, Division 6, Chapter 3.2, is being cited on the attached LIC 9099 D.
An exit interview was conducted and a copy of this report as well as appeal rights were provided via email. A read receipt confirms receipt of these documents.
SUPERVISOR'S NAME: Reyna LaceyTELEPHONE: (951) 836-3135
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3